12 November 1999 - Sifly 3275

The aircraft, an ATR-42-312 with registration F-OHFV, owned by Si Fly but operating on behalf of the UN, World Food Program, departed Rome at 09.11h for Pristina, Kosovo. The plane was at an altitude of 1400 meters and turning left with a 30deg bank when it crashed into a hill (30% slope), 15 meters below the summit. The weather conditions at Pristina were 5000 meters horizontal visibility, sky covered at 700 meters and a compact layer of clouds to 920 meters.

PROBABLE CAUSE:
"The collision of Flight KSV 3275 with high ground was due :
- to teamwork which lacked procedural discipline and vigilance during maneuvers in a mountainous region with poor visibility.
- to the aircraft being kept on its track and then forgotten by a military controller unused to the mountainous environment of the aerodrome and to preventing the risk of collisions with high ground, within the framework of the radar service he was providing.
- to the operator's critical situation as a new company highly dependant on the lease contract, favoring a failure to respect procedures.
- to the opening of the aerodrome to civil traffic without an advance evaluation of the operating conditions or of the conditions for distribution of aeronautical information.

The following factors contributed to the accident :

- crew fatigue, favoring a lowering of vigilance.
- undertaking the flight with an unserviceable or disconnected GPWS.

Download the full report

Transcript of the Cockpit Voice Recorder (CVR)

CAP = Voice identified as Captain
COP = Voice identified as Co-Pilot
RDO = Radio transmission from Captain
CTL = Air traffic controlOPS = Operations
(*) = Words or groups of words not understood
(...) = Words or groups of words which, at the time they were spoken neither interfered with the normal conduct of the flight nor add any elements useful for the analysis or understanding of this event.
[ ] = Transaltion from Italian between these brackets


Time (UTC) Source Content
10.10:40 RDO Kosovo three two seven five
10.10:43 CTL Kosovo three two seven five Pristina pass message
10.10:48 RDO Kosovo check
10.10:49 CAP vediamo un po' che dice [Let's see what he says]
10.10:50 CTL you are loud and clear Sir you're number two to a much faster aircraft just ahead of you now by five miles
10.10:56 RDO okay
10.10:57 CAP euh ci ha messo davanti quell'altro [They've put the other one in front]
10.11:00 CTL just maintain your heading on what you what you are on the moment
10.11:07 CTL euh Hotel Charlie November nine nine three turn left heading two seven zero base leg
10.11:13 ? turn left heading two seven zero niner nine three base leg
10.11:25 CTL Juliet Golf November eight zero request number of persons on board including the crew
10.11:31 ? total passengers on board is euh fifty two
10.11:36 RDO Whiskey four good morning Kosovo three two seven five for check
10.11:36 CTL (*) sir
10.11:44 CAP Tirana era quattro (*) ? [is Tirana four (*) ?]
10.11:45 OPS euh Kosovo three two seven five Whiskey (*) go ahead
10.11:51 RDO I have on board two one people and estimate at two one Pristina
10.11:58 OPS you have two one passengers would you confirm
10.12:04 RDO affirmative two one passengers and two one estimating
10.12:08 CTL roger Charlie November nine nine three turn left heading two one zero report the localizer established
10.12:13 ? turn left heading two one zero wilco
10.12:27 CAP undici miglia [Eleven nautical miles]
10.12:35 COP cazzo io ancora 'sto qui davanti pero' quello che cazzo ci sta'... porca miseria ! [(...) me again, I'm in front, but what is he ... (...) !]
10.12:40 CTL Juliet Golf November eight zero turn left heading three six zero
10.12:42 RDO left three six zero Juliet Golf November eight zero
10.12:50 COP digli we have [Tell him we have]
10.12:51 CAP hanno traffico militare e fanno passa' loro [They've got military traffic and they're letting it pass in front]
10.13:04 CTL Hotel Charlie November nine nine three just confirm your gear is down
10.13:09 ? clearance
10.13:11 CTL roger Sir
10.13:13 RDO Kosovo three two seven five
10.13:15 CTL three two seven five Pristina
10.13:18 RDO I I want to land
10.13:20 CTL roger turn left heading two seven zero
10.13:24 RDO two seven zero turning left
10.13:28 COP eh cazzo
10.13:38 CTL Hotel Charlie November nine nine three you're cleared to land on runway one seven circuit is clear the wind three three zero seven knots
10.13:43 CTL cleared to land runway one seven
10.14:06 CTL Kosovo three two seven five what is you estimated position from the Papa Romeo India
10.14:14 COP position rispetta Papa Romeo India [position relative to Papa Romeo India]
10.14:15 RDO euh fifteen nautical miles now heading two seven zero CdB
10.14:20 CTL Kosovo three two seven five roger turn left heading one eight zero
10.14:24 RDO turning left one eight zero
10.14:27 CTL apologies for the delay sir
10.14:30 CAP eh eh cazzo
10.14:31 Alternator sound
10.14:33 continuous repetitive chime to the end (6 seconds)
10.14:37 COP duecentoquaranta di radar altimetro [Two hundred and forty on the radar altimeter]
10.14:39 End of recording